Question

A nurse is caring for a client who has pneumonia.

1300:
Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified.​
Complete the following sentence by using the list of options.
The nurse should identify that the client might be experiencing ______ as evidenced by the client's _______.
a) Phlebitis; IV catheter site condition
b) Infection; intense pain report
c) Infiltration; IV catheter site presentation
d) Thrombophlebitis; blanched and edematous area

Answer 1

The nurse should identify that the client might be experiencing infiltration as evidenced by the client's IV catheter site presentation.

Step-by-step explanation:

The nurse should identify that the client might be experiencing infiltration as evidenced by the client's IV catheter site presentation.

Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. This can cause symptoms such as pain, tautness, blanching, coolness, and edema at the catheter site. Infiltration should be addressed promptly by discontinuing the IV medication, removing the catheter, and notifying the healthcare provider.